Dr. Goodsleep

How one woman beat insomnia and learned to love bedtime

I used to think of myself as complex, angst-ridden—tormented, even. It wasn't because of a grave psychological disorder. I've never had so much as one suicidal thought or psychotic break. I wasn't wrongfully imprisoned or living with a deadly disease or anything like that. No, the dark problem that dogged me was insomnia, an escalating agony that grew to rule my life in my late twenties and early thirties. I. Could. Not. Sleep. Not in a bed or on the couch. Not on vacation or in my house. Not alone or with my spouse. I could not sleep here or there. I could not sleep anywhere. Deprive yourself of sleep long enough and even the sunniest soul begins to see herself as a cross between Marilyn Manson and the Grinch (both in appearance and attitude).

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So I consulted: two general practitioners, two specialists in "complementary medicine," three psychologists, one psychopharmacologist, two doctors of Chinese medicine, a homeopath, a chiropractor, an astrologer, the medical director of a fancy spa, and a shaman. I was told alternately that I was anxious, that I was depressed, and that I was anxious because I wasn't allowing myself to be depressed. I was told that my life was too chaotic and I needed to get organized, and that I was too organized and needed to look at my control issues. Several people opined that my Saturn was in return. I had many long conversations about the source of my recurring nightmares (I awaken to discover I'm paralyzed, while some not-very menacing but somehow terrifying creature—a toddler, a dried apple doll, and, my favorite, a potbellied pig in a porkpie hat—sits at the end of my bed watching me). I read self-help books, I meditated, I bathed in lavender oil, I took pills: Ambien, Ativan, Klonopin, Tylenol PM, Valium, Xanax. If anything worked, it was fleeting. Eventually I would find myself back in the heart of darkness, lying awake, filled with self-pity, cataloguing all that was wrong with me, with my life, with my job, with my friends, with my boyfriend, with the world. The horror, the horror.

Poor sleep is a serious problem and one that women are twice as likely as men to complain of. Among other things, fluctuations in our hormones seem to make us more vulnerable: menstruation, pregnancy, and perimenopause are known to disrupt sleep. The consequences of bad sleep may be more dire for women too. Recent epidemiological data has shown that inadequate sleep is associated with a greater risk for illnesses such as hypertension, diabetes, and heart disease in women than it is in men. Plus, not getting enough sleep has been shown to make you fat (seriously).

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And now a study that came out this spring backs up the epidemiology and offers some of the first biological clues as to why women pay a bigger price when they don't sleep. Researchers from Duke University looked at 210 healthy men and women ages 18 to 65, none of whom had a clinical sleep disorder, such as sleep apnea. They gave the participants questionnaires about their nocturnal habits and mental health and took blood samples. About 40 percent of the group, both men and women, were categorized as poor sleepers. Being a poor sleeper—in particular, taking more than half an hour to fall asleep or having trouble falling asleep more than two nights a week—seemed to exact both a physical and psychological toll on the women but not on the men. Poor sleep in women was associated with greater feelings of hostility, anger, and depression and appeared to increase their blood levels of insulin, fibrinogen, and the inflammatory biomarkers C-reactive protein and interleukin-6, all of which are associated with diabetes and heart disease.

Study author Edward Suarez, PhD, associate professor of psychiatry, says it's uncertain why women's bodies reacted more negatively, but that gender differences in hormones and brain chemistry likely play a role. Women seem to be more sensitive to imbalances in the serotonergic system, which helps regulate sleep, mood, and bodily functions like insulin production. He also hypothesizes that men's higher testosterone levels may protect against the negative health effects of a sleepless night.

All of this is interesting, but "stop being female" isn't advice that most sleepless women will find actionable. And while drugs may make people fall asleep faster, some can carry risks such as sleep eating and driving, and possibly even addiction. Instead, Suarez and other sleep researchers I spoke to suggest that it may be time for a return to simple behavioral solutions for sleeplessness, often called "sleep hygiene."

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Amy R. Wolfson, PhD, an associate professor of psychology at the College of the Holy Cross and author of The Woman's Book of Sleep, says that after reading Michael Pollan's In Defense of Food, about how the onslaught of nutritional information and the industrialization of food production has actually made it harder to eat well, she was struck by the similarities to the area of sleep science (which has given birth to a multibillion-dollar industry). "We can be guilty in that arena," she says. "We keep giving people lots of information, and you confuse what's most important."

Paying attention to lifestyle may be particularly vital to women, Wolfson says, because they often have more roles and do more caretaking than men—and tend to be less willing to put their own needs ahead of others. Research shows, she says, that while "taking on multiple roles and responsibilities can have a positive psychological effect [for women], the more things people are doing during the day, the more likely they are to have poor-quality sleep."

Suarez says he sees this all the time in his female patients, who often don't even recognize how much multitasking they're doing. He points to a study his lab did years ago looking at stress hormones in working women. Cortisol normally goes up during the day and when you're stressed, and then goes down at night and when you're relaxed. Among working mothers, however, "these women went home and their cortisol levels remained as if they were at work. There was not an unwinding. It was always high."

To combat this effect, Wolfson recommends putting yourself to sleep as you would a small child. "We're good about thinking of bedtime routines for children but not for ourselves," she says. When you think about it, we would never in a million years subject a child to most of the sleep-stealing habits adults cling to: caffeine consumption, smoking, late-night dinners, a glass of scotch or wine at bedside, TVs glowing in the bedroom, squeezing in workouts at night, laptops and BlackBerries in bed, erratic schedules, bedtimes that don't allow for a healthy amount of sleep, and so on. For many of us, the state would declare us unfit guardians if we treated a child the way we treat ourselves. Furthermore, if a toddler were guzzling Coke and bouncing off the walls until bedtime and then blasting a Shrek video from a TV in their room while they tried to fall asleep, you wouldn't think their insomnia was the result of some deep-seated psychological problem. You wouldn't medicate them or send them to yoga class. You'd just take away the soda and TV, right?

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Teaching my son to sleep was ultimately what helped me vanquish my insomnia. One night, when he was six months old and still keeping us up at all hours, I cracked under the intense sleep deprivation. I carried the baby into the living room, turned on all the lights, and put him down on his playmat, sobbing, "You want to play? Fine! Play!" My husband stumbled out of the bedroom, rubbing his eyes, and said, "Why are you yelling at the baby?" I fell to my knees, head in hands, and wailed, "Because he's being a f--king a--hole!"

That's when Richard Ferber, MD, director of the Center for Pediatric Sleep Disorders at Children's Hospital Boston, entered our lives. I read his book Solve Your Child's Sleep Problems cover to cover the next day, and within a week we had the baby blissfully sleeping through the night. This allowed me to finally go back to my former practice of losing sleep for no reason whatsoever. Lying awake at 3 a.m., I began to wonder: If I could so easily "Ferberize" (as the process is known) my son, why not Ferberize myself?

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Ferber says that tuning in to your offspring's circadian rhythms is the most important step in encouraging healthy sleep habits. He divides people into larks and owls—those with a natural early-to-bed, early-to-rise proclivity and those who are biologically most alert in the wee hours. Sleepiness comes in waves, Ferber writes, and you have to catch the wave and remove influences that might make you miss it. To do this, you develop a regular schedule and bedtime routine and remove anything—noise, light, sleep associations like a dependence on bottles or rocking—that interferes with the baby's ability to fall back asleep if he does occasionally rouse. Ferber poses the process as part of responsible parenting, as a way to become comfortable with setting reasonable limits for your child.

When I set out to Ferberize myself, however, I found it much harder to set my own limits. First, I had to face the fact that I was a lark. While being an early bird is associated with all sorts of positive attributes in this country (hardworking, good at worm-catching), living in Manhattan, where everyone is at the office until 8 p.m. and nothing interesting happens until even later, it just makes you sort of a lame, friendless loser. I had to start eating dinner without my husband (who typically works late) and thinking of 9 p.m. as the hour I should turn off the TV and start getting ready for bed. Lights out in our house is now 10 p.m. I had been drinking caffeine only first thing in the morning (and even then, just one cup of tea or a half-caf latte), but I gave it up (oh, the two-day-long headache that ensued). While most people can handle a morning cup of coffee as long as they avoid it in the afternoon, I had to accept that my system was just too sensitive.

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My husband and I had a beautiful queen-size bed that was the first piece of furniture we bought together. But his snoring, twitching, and extreme early rising (he gets up at 5:15 a.m. most workdays) often woke me (and led to stupid fights). A friend passed on what she said was the best piece of advice a couples counselor ever gave her: Get a king-size bed. So the good bed went into storage and a giant, cheap, ugly platform bed now dominates our bedroom. On the weekends, even when my husband is willing to get up with my son, I don't sleep in and I never nap.

I won't lie: All that sacrificing sucked, and I still struggle to stay on schedule. On the other hand, I get seven or eight hours of sleep a night—and I've discovered the joy of waking up rested, without an alarm. Sometimes I choose to push my limits, staying up late to see friends or meet a deadline, but then I'm not surprised when my sleep unravels for a night or two. I recently phoned Ferber to tell him about my success using his method on myself.

"Have lots of other parents told you they Ferberized themselves?" I asked.

"Actually, no," he said, after a pause. "Nobody's put it quite like that."

I told him my one trouble adapting the program for adults. Though we easily convinced our son that the wee hours were "sleepy time" and taught him to fall back asleep in the middle of the night without nursing or rocking, I haven't been able to teach myself to do the same thing. It's the most stubborn artifact of my former insomniac existence, one that tends to bother me most when I'm anxious about something. I'll surface from a dream and tell myself, "Don't think about it, don't think about it," but soon I'm wide awake, polishing that little nugget of worry and stressing about not sleeping, sometimes for an hour, sometimes until dawn. Was there any way I could teach myself to "self-soothe" as well as my son does?

"That's really an issue of sleep drives," Ferber told me. Humans evolved with the night's sleep divided into two portions of heavy sleep, with a lighter period in the middle. "If you wake up after that first period of heavy sleep and you're worried about something and start thinking about it, you may not have enough sleep drive left to fall back asleep immediately," he explains. "One of the best things you can do at that point is say, `I'm awake.' And don't get frustrated. Just wait until that sleepiness comes back. You can't force yourself to sleep, but you can certainly keep yourself awake."

This advice dovetails with what my mother has told me since I was a child: When you can't sleep, don't try to not think; it only leads to a night of whirring anxiety. Instead, engage your mind in something pleasurable (when I was little she'd tell me to imagine the prettiest dress in the world). I began to use her technique after speaking to Ferber and have found it extremely effective—embarrassingly so, given how many remedies I've tried. I feel a bit like Dorothy in The Wizard of Oz: I went searching far and wide only to find my heart's desire was in my backyard (or, at least, the back of my mind) the whole time.

Why is it that we can never accept that our problems are run-of-the-mill? Why do we resist commonsense advice and instead turn to drugs and complicated programs? Actually, forget "we": Why do I do this? Am I a narcissist? A drama queen? A moron? It's an issue I'll have to contemplate—but not at 3 a.m. That's my time for thinking about pretty dresses.

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